A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
Evaluate the firmness of the uterus (fundus).
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
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Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While a urinary tract infection can cause frequent urination, it’s usually accompanied by other symptoms such as pain or burning during urination.
Choice B rationale:
Trauma to pelvic muscles can cause urinary incontinence, not necessarily increased frequency.
Choice C rationale:
Urinary overflow is a condition where the bladder is always full and can lead to frequent leakage of urine.
Choice D rationale:
Postpartum diuresis is the body’s way of getting rid of excess fluid accumulated during pregnancy, leading to increased urine production and frequency.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While oxytocin sensitivity is important for labor, there is no evidence to suggest that Braxton Hicks contractions increase oxytocin sensitivity.
Choice B rationale:
Prostaglandins play a crucial role in labor by causing the cervix to soften and dilate and the uterus to contract. However, there is no evidence to suggest that Braxton Hicks contractions increase the release of prostaglandins.
Choice C rationale:
While maternal comfort is important during labor, there is no evidence to suggest that Braxton Hicks contractions make maternal breathing easier.
Choice D rationale:
Braxton Hicks contractions help in softening and ripening the cervix, which is an important part of preparing for labor.
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